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Leshen MA, Devanagondi R, Saul D, Chaturvedi A. Physiological fetal vascular shunts and failure to regress: what the radiologist needs to know. Pediatr Radiol 2022; 52:1207-1223. [PMID: 35166890 DOI: 10.1007/s00247-022-05302-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 09/13/2021] [Accepted: 01/27/2022] [Indexed: 10/19/2022]
Abstract
The fetal circulation is characterized by the presence of three physiological vascular shunts - the ductus arteriosus, the foramen ovale and the ductus venosus. Acting in concert, these shunts preferentially stream blood flow in a pattern that maximizes efficiency of blood oxygenation by the maternofetal unit. Shortly following the transition to extrauterine life, a quick and predetermined succession of events results in closure of these embryological structures with consequent establishment of postnatal vascular flow patterns. While this transition is often seamless, the physiological shunts of the fetus occasionally fail to regress. Such failure to regress can occur in isolation or in association with other congenital malformations. This failed regression challenges the circulatory physiology of the neonate and might have implications for the optimum functioning of several organ systems. When symptomatic, these shunts are treated. Interventions, when undertaken, might be medical, endovascular or surgical. The radiologist's role continues to expand in the assessment of these shunts, in providing a roadmap for treatment and in prompt identification of treatment-related complications. This review is to familiarize radiologists with the embryology, pre- and post-treatment imaging appearances, and associated complications of persistent fetal vascular shunts.
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Affiliation(s)
- Michael A Leshen
- Department of Imaging Sciences, University of Rochester Medical Center, 601 Elmwood Ave., Rochester, NY, 14642, USA.
| | - Rajiv Devanagondi
- Division of Pediatric Cardiology, Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, USA
| | - David Saul
- Department of Medical Imaging, A. I. DuPont Hospital for Children, Wilmington, DE, USA
| | - Apeksha Chaturvedi
- Pediatric Imaging Section, Department of Imaging Sciences, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
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2
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Vizzari G, Pizzino F, Zwicke D, Tajik AJ, Carerj S, Di Bella G, Micari A, Khandheria BK, Zito C. Patent foramen ovale: anatomical complexity and long-tunnel morphology related issues. AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2021; 11:316-329. [PMID: 34322302 PMCID: PMC8303044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/05/2021] [Indexed: 06/13/2023]
Abstract
Patent foramen ovale (PFO) is present in about one-quarter of the population and should be considered an anatomical variant rather than a malformation. The association of PFO with cryptogenic stroke, migraine, peripheral embolism and other pathologies is still controversial. The evaluation of anatomical complexity, and particularly the long-tunnel morphology, is crucial for the assessment of the risk profile and for a targeted therapeutic management. Long-tunnel PFOs seem to be more prone to clot formation and complications related to percutaneous closure procedures. Echocardiography is the most useful method to investigate anatomical complexity, confirm and reinforce the indication to treatment, select the appropriate device and guide the PFO closure towards a successful procedure.
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Affiliation(s)
- Giampiero Vizzari
- Department of Clinical and Experimental Medicine, University of Messina, A.O.U. Policlinic “G. Martino”Messina 98165, Italy
| | - Fausto Pizzino
- Cardiology Unit, Conegliano Hospital, AULSS2 Marca TrevigianaConegliano (TV) 31015, Italy
| | - Dianne Zwicke
- Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, University of Wisconsin School of Medicine and Public Health2801 W. Kinnickinnic River Parkway, #840, Milwaukee, WI 53215, USA
| | - A Jamil Tajik
- Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, University of Wisconsin School of Medicine and Public Health2801 W. Kinnickinnic River Parkway, #840, Milwaukee, WI 53215, USA
| | - Scipione Carerj
- Department of Clinical and Experimental Medicine, University of Messina, A.O.U. Policlinic “G. Martino”Messina 98165, Italy
| | - Gianluca Di Bella
- Department of Clinical and Experimental Medicine, University of Messina, A.O.U. Policlinic “G. Martino”Messina 98165, Italy
| | - Antonio Micari
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, A.O.U. Policlinic “G. Martino”Messina 98165, Italy
| | - Bijoy K Khandheria
- Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, University of Wisconsin School of Medicine and Public Health2801 W. Kinnickinnic River Parkway, #840, Milwaukee, WI 53215, USA
| | - Concetta Zito
- Department of Clinical and Experimental Medicine, University of Messina, A.O.U. Policlinic “G. Martino”Messina 98165, Italy
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3
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Giblett JP, Williams LK, Kyranis S, Shapiro LM, Calvert PA. Patent Foramen Ovale Closure: State of the Art. Interv Cardiol 2020; 15:e15. [PMID: 33318751 PMCID: PMC7726850 DOI: 10.15420/icr.2019.27] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 09/22/2020] [Indexed: 12/29/2022] Open
Abstract
Patent foramen ovale (PFO) is a common abnormality affecting between 20% and 34% of the adult population. For most people, it is a benign finding; however, in some people, the PFO can open widely to enable paradoxical embolus to transit from the venous to arterial circulation, which is associated with stroke and systemic embolisation. Percutaneous closure of the PFO in patients with cryptogenic stroke has been undertaken for a number of years, and a number of purpose-specific septal occluders have been marketed. Recent randomised control trials have demonstrated that closure of PFO in patients with cryptogenic stroke is associated with reduced rates of recurrent stroke. After a brief overview of the anatomy of a PFO, this article considers the evidence for PFO closure in cryptogenic stroke. The article also addresses other potential indications for closure, including systemic arterial embolisation, decompression sickness, platypnoea-orthodeoxia syndrome and migraine with aura. The article lays out the pre-procedural investigations and preparation for the procedure. Finally, the article gives an overview of the procedure itself, including discussion of closure devices.
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Affiliation(s)
- Joel P Giblett
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital Liverpool, UK
| | - Lynne K Williams
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust Cambridge, UK
| | - Stephen Kyranis
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust Cambridge, UK
| | - Leonard M Shapiro
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust Cambridge, UK
| | - Patrick A Calvert
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust Cambridge, UK
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4
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Abstract
Patent foramen ovale (PFO) is a common abnormality affecting between 20% and 34% of the adult population. For most people it is a benign finding; however, in some the PFO can open widely, enabling a paradoxical embolus to transit from the venous to arterial circulation, which is associated with stroke and systemic embolisation. Percutaneous closure of PFO in patients with cryptogenic stroke has been undertaken for a number of years, and a number of purpose-specific septal occluders have been marketed. Recent randomised controlled trials have demonstrated that closure of PFO in patients with cryptogenic stroke is associated with reduced rates of recurrent stroke. After a brief overview of the anatomy of a PFO, this review considers the evidence for PFO closure in cryptogenic stroke. The review also addresses other potential indications for closure, including systemic embolisation, decompression sickness, platypnoea-orthodeoxia syndrome and migraine with aura. It lays out the pre-procedural investigations and preparation for the procedure. Finally, it gives an overview of the procedure itself, including discussion of closure devices.
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Affiliation(s)
- Joel P Giblett
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust Cambridge, UK.,Division of Cardiovascular Medicine, University of Cambridge Cambridge, UK
| | - Omar Abdul-Samad
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust Cambridge, UK
| | - Leonard M Shapiro
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust Cambridge, UK
| | - Bushra S Rana
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust Cambridge, UK
| | - Patrick A Calvert
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust Cambridge, UK.,Division of Cardiovascular Medicine, University of Cambridge Cambridge, UK
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5
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Hardt SE, Eicken A, Berger F, Schubert S, Carminati M, Butera G, Grohmann J, Höhn R, Nielsen-Kudsk JE, Hildick-Smith D, Settergren M, Thomson JD, Geis N, Søndergaard L. Closure of patent foramen ovale defects using GORE® CARDIOFORM septal occluder: Results from a prospective European multicenter study. Catheter Cardiovasc Interv 2017; 90:824-829. [PMID: 28296023 DOI: 10.1002/ccd.26993] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 01/15/2017] [Accepted: 01/28/2017] [Indexed: 01/24/2023]
Abstract
AIMS The GORE® CARDIOFORM Septal Occluder (GSO) is a novel device designed for rapid and effective closure of patent foramen ovale (PFO) which has distinctive features making it suitable for a broad spectrum of anatomical variations. We report the procedural and 6 months follow-up results of the first prospective, multicenter study using GSO. METHODS AND RESULTS This single-arm study included 150 subjects undergoing closure of PFO in 10 European centers. In 149 out of 150 patients implantation of a GSO device was successful. One patient had a different PFO-closure device implanted. Periprocedural complications were few including one patient with suspected transient ischemic attack, two access site bleedings, and one patient with AV-fistula. No device embolization occurred. During the 6-month follow-up period one patient had a transient asymptomatic thrombus on the device and four patients (2.6%) were diagnosed new onset paroxysmal atrial fibrillation, which were successfully treated. No thrombembolic events occurred. Closure was successful in 94.2% of subjects at discharge evaluation and 96.9% at 6 months follow-up. CONCLUSION This prospective, multicenter study adds to previous published data and suggests that GSO is a versatile device for PFO closure with high procedural and closure success rates and low complication rates through mid-term follow-up. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Stefan E Hardt
- Department of Cardiology, Angiology, and Pulmology, University of Heidelberg, Heidelberg, Germany.,Center for Cardiac and Circulatory Diseases, Bruchsal, Germany
| | - Andreas Eicken
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universität, Munich, Germany
| | - Felix Berger
- Klinik für Kinderkardiologie und angeborene Herzfehler, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Stephan Schubert
- Klinik für Kinderkardiologie und angeborene Herzfehler, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Mario Carminati
- Department of Paediatric Cardiology and Cardiac Surgery and Adult Congenital Heart Disease, IRCCS Policlinico San Donato, Milan, 20097, Italy
| | - Gianfranco Butera
- Department of Paediatric Cardiology and Cardiac Surgery and Adult Congenital Heart Disease, IRCCS Policlinico San Donato, Milan, 20097, Italy
| | - Jochen Grohmann
- Department of Congenital Heart Defects and Pediatric Cardiology, Heart Center, University of Freiburg, Freiburg, Germany
| | - Rene Höhn
- Department of Congenital Heart Defects and Pediatric Cardiology, Heart Center, University of Freiburg, Freiburg, Germany
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology-Research, Institute of Clinical Medicine, Aarhus University Hospital Skejby, Aarhus N, DK-8200, Denmark
| | | | - Magnus Settergren
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - John D Thomson
- Department of Congenital Cardiology, Leeds General Infirmary, Leeds, United Kingdom
| | - Nicolas Geis
- Department of Cardiology, Angiology, and Pulmology, University of Heidelberg, Heidelberg, Germany
| | - Lars Søndergaard
- The Heart Centre, Rigshospitalet University Hospital, Copenhagen, 2100, Denmark
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6
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Lew KN, Angelini GD, Hollingworth W. A time-series study of percutaneous closure of patent foramen ovale: premature adoption? Open Heart 2016; 3:e000313. [PMID: 26835140 PMCID: PMC4716454 DOI: 10.1136/openhrt-2015-000313] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 08/25/2015] [Accepted: 10/13/2015] [Indexed: 12/27/2022] Open
Abstract
Objectives To evaluate the impact of National Institute for Health and Care Excellence (NICE) guidance in January 2005 and subsequent trial evidence on the adoption of percutaneous closure of patent foramen ovale (PCPFO). Methods A retrospective time series study was conducted using the Inpatient Hospital Episode Statistics (HES) England. A total of 3801 patients, aged ≥18 and ≤60 years, who had PCPFO from 1 April 2006 to 31 March 2012 in England. Percentage change annualised (PCA) in PCPFO procedure rates between initial NICE guidance and publication of trial results was analysed. Results Between Quarter 2, 2006 and Quarter 4, 2009, 2163 PCPFO procedures were performed, with an increasing PCA of 48.4%. The procedure rate peaked before the presentation of equivocal results from the first randomised controlled trial (RCT) in late 2010, and declined between Quarter 4, 2009 and Quarter 4, 2011 (PCA=−15.3%). Of more than 2300 patients recruited to three RCTs, only 71 were recruited in English hospitals. Conclusions PCPFO was rapidly adopted after the publication of initial NICE guidance despite the absence of RCT evidence of efficacy. Very few English patients participated in international RCTs of PCPFO, suggesting that NICE recommendations also failed to encourage the generation of RCT evidence.
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Affiliation(s)
- Kian Nian Lew
- Faculty of Medicine and Dentistry , University of Bristol , Bristol , UK
| | - Gianni D Angelini
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust , Bristol , UK
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7
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Crystal MA, Vincent JA. Atrial Septal Defect Device Closure in the Pediatric Population: A Current Review. CURRENT PEDIATRICS REPORTS 2015. [DOI: 10.1007/s40124-015-0086-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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GEIS NICOLASA, PLEGER SVENT, KATUS HUGOA, HARDT STEFANE. Using the GORE® Septal Occluder (GSO) in Challenging Patent Foramen Ovale (PFO) Anatomies. J Interv Cardiol 2015; 28:190-7. [DOI: 10.1111/joic.12181] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- NICOLAS A. GEIS
- Department of Internal Medicine III; University of Heidelberg; Germany
| | - SVEN T. PLEGER
- Department of Internal Medicine III; University of Heidelberg; Germany
| | - HUGO A. KATUS
- Department of Internal Medicine III; University of Heidelberg; Germany
| | - STEFAN E. HARDT
- Department of Internal Medicine III; University of Heidelberg; Germany
- Center of Cardiac and Circulatory Diseases; Bruchsal Germany
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9
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Grohmann J, Höhn R, Fleck T, Schmoor C, Stiller B. Transcatheter closure of atrial septal defects in children and adolescents: Single-center experience with the GORE® septal occluder. Catheter Cardiovasc Interv 2014; 84:E51-7. [DOI: 10.1002/ccd.25494] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 02/27/2014] [Accepted: 03/12/2014] [Indexed: 11/05/2022]
Affiliation(s)
- J. Grohmann
- Department of Congenital Heart Defects and Pediatric Cardiology; Heart Center, University of Freiburg; Freiburg Germany
| | - R. Höhn
- Department of Congenital Heart Defects and Pediatric Cardiology; Heart Center, University of Freiburg; Freiburg Germany
| | - T. Fleck
- Department of Congenital Heart Defects and Pediatric Cardiology; Heart Center, University of Freiburg; Freiburg Germany
| | - C. Schmoor
- Clinical Trials Unit, Medical Center, University of Freiburg; Freiburg Germany
| | - B. Stiller
- Department of Congenital Heart Defects and Pediatric Cardiology; Heart Center, University of Freiburg; Freiburg Germany
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10
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Knerr M, Bertog S, Vaskelyte L, Hofmann I, Sievert H. Results of percutaneous closure of patent foramen ovale with the GORE®septal occluder. Catheter Cardiovasc Interv 2014; 83:1144-51. [DOI: 10.1002/ccd.25336] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 11/11/2013] [Accepted: 11/27/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Meike Knerr
- CardioVascular Center, Seckbacher Landstraße 65, 60389; Frankfurt Germany
| | - Stefan Bertog
- CardioVascular Center, Seckbacher Landstraße 65, 60389; Frankfurt Germany
| | - Laura Vaskelyte
- CardioVascular Center, Seckbacher Landstraße 65, 60389; Frankfurt Germany
| | - Ilona Hofmann
- CardioVascular Center, Seckbacher Landstraße 65, 60389; Frankfurt Germany
| | - Horst Sievert
- CardioVascular Center, Seckbacher Landstraße 65, 60389; Frankfurt Germany
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11
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Thomson JD, Hildick-Smith D, Clift P, Morgan G, Daniels M, Henderson R, Spence MS, Mahadevan VS, Crossland D, Ormerod O. Patent foramen ovale closure with the Gore septal occluder: initial UK experience. Catheter Cardiovasc Interv 2013; 83:467-73. [PMID: 23766247 DOI: 10.1002/ccd.25063] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 05/14/2013] [Accepted: 06/01/2013] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To report procedural outcome and short-term follow-up data for the Gore septal occluder (GSO), a new device for closure of patent foramen ovale (PFO). BACKGROUND Transcatheter closure of PFO is an established treatment modality but no current device provides a perfect solution. The GSO has a number of design features, which make it potentially attractive for closure of defects in the atrial septum. METHODS Data from 9 centers in the United Kingdom implanting the GSO device, submitted to an electronic registry for evaluation. RESULTS Two hundred twenty-nine patients undergoing PFO closure from June 2011 to October 2012 were included. Indications for closure were secondary prevention of paradoxical cerebral emboli (83.4%), migraine (2.1%), platypnoea orthodeoxia (3.9%), and other (10.5%). Median PFO size was 8 mm and 34 and 39%, respectively, had long tunnel anatomy or atrial septal aneurysms. A GSO was successfully implanted in all cases. A single device was used in 98% but in 4 patients the initial device was removed and a second device required. Procedural complications occurred in 3% and later complications (e.g., atrial fibrillation, atrial ectopics, and device thrombus) in 5.7% of cases. All patients have undergone clinical and echocardiographic follow-up and all devices remain in position. Early bubble studies (median 0 months) with Valsalva maneuver in 67.2% were negative in 89%. CONCLUSIONS The GSO is an effective occlusion device for closure of PFO of all types. Longer-term follow-up particularly to document later closure rates are required.
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Affiliation(s)
- John D Thomson
- Department of Congenital Cardiology, Leeds General Infirmary, Leeds, United Kingdom
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12
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Butera G, Saracino A, Danna P, Sganzerla P, Chessa M, Carminati M. Transcatheter PFO closure with GORE®septal occluder: Early and mid-term clinical results. Catheter Cardiovasc Interv 2013; 82:944-9. [DOI: 10.1002/ccd.25106] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 06/12/2013] [Accepted: 06/27/2013] [Indexed: 11/08/2022]
Affiliation(s)
- Gianfranco Butera
- Department of Pediatric Cardiology and GUCH Unit; Policlinico San Donato IRCCS; Milan Italy
| | - Antonio Saracino
- Department of Pediatric Cardiology and GUCH Unit; Policlinico San Donato IRCCS; Milan Italy
| | - Paolo Danna
- Department of Cardiology; Sacco Hospital; Milan Italy
| | | | - Massimo Chessa
- Department of Pediatric Cardiology and GUCH Unit; Policlinico San Donato IRCCS; Milan Italy
| | - Mario Carminati
- Department of Pediatric Cardiology and GUCH Unit; Policlinico San Donato IRCCS; Milan Italy
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13
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Musto C, Cifarelli A, Fiorilli R, De Felice F, Parma A, Nazzaro MS, Guerra E, Fiorilli F, Violini R. Comparison Between the New Gore Septal and Amplatzer Devices For Transcatheter Closure of Patent Foramen Ovale. Circ J 2013; 77:2922-7. [DOI: 10.1253/circj.cj-13-0565] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Carmine Musto
- Interventional Cardiology Unit, San Camillo Hospital
| | | | | | | | - Antonio Parma
- Interventional Cardiology Unit, San Camillo Hospital
| | | | - Elena Guerra
- Interventional Cardiology Unit, San Camillo Hospital
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